ࡱ> '` vbjbjLULU i.?.?T4P 4 V!V!V!V!!D I(J"(r"r"r"r"444HHHHHHH$Jh=M I] 83488 Ir"r"gIS;S;S;8Zr" r"HS;8HS;S;VB@ Cr">" `5V!m9C H}I0ICxN:NCCN pF`4I5S;5l;6444 I I+;(444I8888 V! V!  Guideline for the management of Infants with Moderate or Severe Perinatal Asphyxia requiring cooling. Perinatal asphyxia is an insult to the fetus or newborn infant due to the lack of oxygen (hypoxia) and/or lack of perfusion (ischaemia) to various organs. It is a major cause of death and acquired brain damage with an incidence of 2/1000 live births in the UK. Following acute asphyxia, early compensatory adjustments occur. However, if these fail, cerebral auto-regulation is lost leading to a pressure-passive cerebral blood flow, typically allowing a fall in cerebral blood flow. This leads to intracellular energy failure resulting in immediate cell injury. Following the initial phase of energy failure, cerebral metabolism may recover only to deteriorate in the secondary reperfusion phase. This delayed phase of neuronal injury starts at about 6-24 hours after the initial injury and is characterised by cerebral oedema and apoptosis. During this potential therapeutic window, different treatments for asphyxia have been tried including selective head cooling and total body cooling. Meta-analysis of the data and a Cochrane review concludes that therapeutic hypothermia results in both a clinically important and statistically significant reduction in the combined outcome of mortality or major neuro-developmental disability at 18 months of age. (The NNT in order to prevent one adverse outcome is only 8).  SHAPE \* MERGEFORMAT  Indications for cooling: Babies should be assessed for 3 criteria A, B and C, (as the TOBY trial). Criteria A: Infants e" 36 weeks gestation with one of the following: 1) Apgar score <5 at 10 minutes after birth or 2) Continued need for resuscitation including endotracheal or masked ventilation at10 minutes after birth or 3) pH d" 7 from umbilical cord, or any blood sample obtained from the infant within the first hour of life or 4) Base deficit e"16 mmol in the umbilical cord or any blood sample from the infant within first hour of life. If A is met, then assess for encephalopathy using criteria B Criteria B: Moderate or severe encephalopathy consisting of: 1) Reduced or absent response to stimulation 2) Decreased or no activity 3) Abnormal tone 4) Absent or weak suck, Moro reflex 5) Clinical seizures If the baby meets criteria A & B, then assess for criteria C by amplitude integrated EEG (aEEG) using the CFM (Cerebral function monitor).Do not wait until the CFM trace is available until cooling is started. If the CFM is subsequently completely normal, cooling may be discontinued later. A CFM record of at least 30 minutes duration should be obtained within the first 6 hours of life and should show one of the following if cooling is to be started: 1) Normal background with some electrical seizure activity - Fig B 2) Moderate abnormal trace - Fig C 3) Severely abnormal trace Fig D Fig A: Shows a CFM trace with normal background activity. Upper border of trace >10V and lower border of trace >5V Fig B: Shows a normal background activity with seizures. Seizures appear as an abrupt rise in voltage Fig C: Shows a moderately abnormal trace with the upper border >10V and the lower border <5V. This appearance may also be seen following administration of anticonvulsants and sedatives Fig D: Shows a severely abnormal trace with upper border <10V and lower border <5V. Often there will be bursts of high voltage burst suppression pattern.      Management on Labour Ward: Dry the baby and ventilate in air for 60-90seconds.If the infants colour does not improve, introduce O2 as required. Turn the overhead heater off to avoid hyperthermia. Allow passive hypothermia to occur by not actively re-warming the child. Take the temperature and aim for a target temperature of 34o C to 35o C for initial passive hypothermia. (Be careful as accidental over cooling can easily occur). Transfer to the NICU, nurse in an incubator, with the temperature set at the minimal temperature @ 27OC, insert a rectal thermometer and apply the aEEG electrodes and monitor. If criteria C is not fulfilled (abnormal aEEG in any 30 minute time period within the first 6 hours of life), cooling is not indicated as infants with normal aEEGs are at very low risk for neurological damage. If cooling has been commenced, then rewarm slowly over 4-6 hours. Avoid hyperthermia in these babies for the first few days after birth as hyperthermia is known to increase neurological injury. Consider NOT cooling: if 1) the gestation is < 36 weeks. 2) moribund with persisting severe encephalopathy (as outcome is not improved by cooling). 3) the Infant is likely to require surgery in the first three days of life. Cooling should be used with caution in babies with unstable respiratory and cardiovascular function including those with PPHN (persistent pulmonary hypertension). However, PPHN is not a contraindication for therapeutic hypothermia. Management on the NICU: Obtain full maternal history including signs of pyrexia and/or infection, induction of labour, use of syntocin, instrumental delivery, document the CTG, cord gas, Apgar scores at 1, 5 & 10 minutes, time to first gasp. All details should be recorded on the TOBY register data form obtained from the TOBY website ( HYPERLINK "http://www.npeu.ox.ac.uk/toby" www.npeu.ox.ac.uk/toby).A TOBY PIN number needs to be obtained which can be done during normal working hours Monday to Friday and the telephone number is on the website. Insert a rectal temperature probe up to 6 cm and tape to the thigh. Maintain the rectal temperature between 330C -340C.Two additional temperature probes should be placed one over the back of the infant and one on the tubing. These temperature probes are a safety measure to check that the temperature set on the cooling equipment is being delivered.. Start with the set temperature of 200C in Tecotherm and increase the temperature accordingly as the rectal temperature drops to 350C. Typically in a few hours the set temperature of Tecotherm will be 25 to 300C. The set temperature will vary with each baby and is dependant on both infant size and activity. Obtain central access: double lumen UVC and a UAC. Send bloods for: full blood count, electrolytes, clotting screen, liver function test, blood glucose, blood gases and lactate. Discuss hypothermia with the parents, give them the TOBY register parent information leaflet, document discussions and obtain consent on your trust consent form. (Cooling is becoming the standard of care in asphyxia thus formal consent may not be required. Please be guided by your local clinician/trust policy). Potential adverse effects of cooling: Impaired cardiac function, disordered coagulation, thrombocytopenia, hypokalaemia, increased risk of sepsis, subcutaneous fat necrosis have all been reported with hypothermia. Specific management: Poor skin perfusion occurs during cooling, thus inspect the back at least 12 hourly and vary the position 6 to 12 hourly from flat to slightly tilted in the supine position. Once cooling is established, aim for minimal handling. Respiratory: Ventilate only if required. Cooled neonates can often be managed on CPAP. Use humidified and heated gases as normal. Patients may need frequent suctioning as the ETT secretions become sticky when cold, this usually happens by day 2 or 3. Avoid hypocapnia. Keep Pa02 8 to 13 kPa, and PC02 6 to 8 kPa (the blood gas analyser assumes the temperature is 370C and so will over-read by 0.83kPa/0C drop in temperature in cooled infants. Cardiovascular: Hypothermia causes sinus bradycardia: the heart rate drops by 14 beats/min/oC drop in temperature. Observe for hypotension. There may be a borderline increase in the requirement for inotropic support in cooled patients. Keep the MABP within the normal range of 45 mm to 65 mm of Hg. Treat hypotension as per local hypotension guidelines. Echocardiographic assessment of the degree of filling may prove useful (cooled patients may develop capillary leak and an echo will help guide volume replacement). Fluids: Start with 40 to 60 ml/kg/day of 10% dextrose. Monitor the blood glucose regularly as there may be a need for higher than normal glucose infusion rate (GIR). Normal GIR is 6 mg/kg/min. Fluid boluses should be used with caution as it can lead to marked oedema - Cooling can exacerbate oedema because of capillary leak. CNS: The stress of shivering and feeling cold may interfere with neuro-protection. Sedate with morphine infusion 10 to 25 mcg/kg/hour. Hypothermia affects morphine metabolism so potentially toxic serum concentration of morphine may occur with infusions >10 mcg/kg/hour. Reduce the morphine infusion to 5 to 8 mcg/kg/hour after 12 to 24 hours and continue to monitor for signs of stress. If the patient has a normal heart rate and a normal blood pressure despite hypothermia, consider increasing the morphine infusion as stress can cause this clinical picture. Use vecuronium infusion for paralysis. As drug accumulation occurs during hypothermia, unpredictable drug levels may occur. Stop vecuronium at 12 to 24 hours and resume when movements occur. Seizure management: Phenobarbitone 20 mg/kg IV over 20 minutes for up to 2 doses. The half life of phenobarbitone is increased during cooling. If seizures persist use Phenytoin 20 mg/kg, BUT use only one dose. If seizures continue, start a Midazolam or Clonazepam infusion, dependant on local policy. If seizures difficult to control, a Lidocaine infusion may be used. Do not use if phenytoin has been given as both drugs given together will cause cardiac depression. Haematology Hypothermia causes a significant increase in thrombocytopenia with concomitant reduction in platelet function, thus aim to keep platelets >50109/mm3. Hypothermia increases blood viscosity, so keep the haematocrit d" 65. Cooling may worsen abnormal clotting. Treat clotting abnormalities aggressively as per local policy. Infection: Use first line antibiotics as per local policy. In UHW, use Benzyl penicillin and Gentamicin. Remember to check Gentamicin level as HIE may affect renal function. Neuro imaging: Perform a cranial USS soon after birth and at 24 hours with doppler imaging of the anterior cerebral artery to obtain the resistive index (RI). A resistive index of <0.5 is indicative of a poor prognosis as it suggests compensatory vasodilatation is occurring after the hypoxic-ischaemic insult. Obtain an MRI scan between 5 and 14 days as this is helpful for prognosis. Normal myelination pattern in the posterior limb of the internal capsule is associated with normal outcome. Extensive white matter abnormalities and loss of grey white differentiation are associated with an abnormal outcome. Cooled neonates should be followed up for at least 2 years to ascertain neuro-developmental outcome. Re-warming: After 72 hours, start to rewarm the baby. Increase the babys temperature by 0.50C/hour.This should take 6 to 8 hours. Continue to record the rectal temperature throughout this period. Rapid re-warming may cause seizures or hypotension. If this happens, stop re-warming and re-cool and attempt re-warming again after 6-8 hrs. Treat seizures and hypotension as per local policy. Therapeutic hypothermia for infants born outside cooling centres: If a baby is born with signs of perinatal asphyxia, assess for eligibility criteria A & B and if fulfilled treatment should be started locally whilst transport to a cooling centre is being arranged (Cooling centres are UHW, RGH Newport and Singleton hospital, Swansea). Switch the overhead warmer off. Insert a rectal temperature probe if available and keep the temperature at 34 to 350C. Inform the parents about cooling treatment and give the parent information leaflet available on the TOBY register website. Continue with standard intensive care with the addition of passive hypothermia. Do not use fans/cold compresses as they will overcool the infant and this may be as detrimental to the patient as hyperthermia. Transport the infant to a cooling centre in a transport incubator. Set the incubator temperature slightly lower than normal (1-20C). It is very easy to overcool during transport, often babies will require increasing the set incubator temperature in order to avoid overcooling. References: 1. Shankaran S., et al. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med, 2005. 353(15): p. 1574-84. 2. Volpe JJ. Neurology of the newborn. Fifth Edition, Philadelphia, W.B. Saunders, 2008 3. Azzopardi D Et al. TOBY study. Whole body hypothermia for the treatment of perinatal asphyxial encephalopathy: Randomized controlled trial. BMC Pediatrics 2008, 8:17 4. Jacobs SE et al. Cooling for newborn with hypoxic ischaemic encephalopathy: Cochrane database of systematic review. 2007, Issue 4, Art No.: CD003311. DOI: 10.1002/14651858. CD 003311.pub2. 5. Rutherford M et al. Mild Hypothermia and the Distribution of Cerebral Lesions in Neonates With Hypoxic-Ischemic Encephalopathy. Pediatrics, Oct 2005; 116: 1001 - 1006. 6. Rutherford M et al. Abnormal Magnetic Resonance Signal in the Internal Capsule Predicts Poor Neurodevelopmental Outcome in Infants with Hypoxic-Ischemic Encephalopathy. Pediatrics, Aug 1998; 323 - 328. Anitha James, Shobha Cherian August 2009. To be reviewed August 2012 Fig A: Normal trace: Lower margin >5V, upper margin >10V, sleep wake cycling Fig B: Normal background with some electrical seizure activity Fig C: 6Sdefgyz ( 8 M W j k l     * 4 > H _ % H | ~~ww h'Jh;~ h'Jh: h'Jhn h'Jh h'JhJ h'JhL h'Jh h'Jh]@ h'J h'Jh h'Jh* h'Jh_ahoIh,CJ aJ h'Jh]CJ(aJ(h'J5CJ(aJ(h'Jh,5CJ(aJ(h'Jh_a5CJ(aJ(.fgl LMzgd,gdr`gd,]gdoIgdSgd*.].gd'JT?v + g x ! U c d ֽuihZhgbM5CJaJhI!h,CJaJ jhEhYo5CJUaJ)jhE5CJUaJmHnHtH uhE5CJaJjhE5CJUaJh'Jh{.mH sH  h'Jhf h'Jh9}} h'Jh5d h'Jh: h'Jh h'JhJ h'Jh h'Jhsi& 26FJn*.BDr~žžŴ̜̘̜̜̜̜̑̑hThrCJ aJ h'JhrhoIh%9h'JhS5hTh'J5CJ aJ h'JhS5>* h'JhgbM h'Jhsi h'Jh, h'JhShsi5>*CJaJhShS5>*CJaJhZhS5CJaJ0LM  $-CJNnfj1@AƿưhoIh'J5CJ aJ hoI h'Jh'J h'Jh%9h%9 h'JhZh#T h'Jhh#Th,5 h'Jhrs h'Jh9}} h'JhS h'JhSB h'JhrhT h'Jh,h'JhS5hTh,CJ aJ 2@Avwz{|}gd9`gd'Jgd'Jgd,AF!wxy|}~Ӿ~ul\Gl)jhv 5CJUaJmHnHtH ujhv UmHnHtH uh #5CJaJh;y5CJaJjhE&UmHnHtH ujhE&UmHnHsH u)jhE&5CJUaJmHnHsH u h'JhE&hE&)jhE&5CJUaJmHnHtH ujhE&UmHnHuh'Jh95 h'Jh9 h'Jh$$h'Jh$$5)*-Ob÷}v}}n}g`}`}Y}Y} h7zh h7zhSB h7zhh7zhY&H* h7zhsi h7zhrs h7zhY&hThTCJ aJ hZhsi5CJaJhZhSB5CJaJhHvJ5CJaJhoIhE&5CJaJhE&5CJaJh;y5CJaJ)jhv 5CJUaJmHnHtH uh #5CJaJh9h #5CJaJ")J%qrZ[stO"O" & Fgdf & FgdHvJgd3Ggdrsgd, 6JRVZ^_eq#$%&(ջܴܴܴܴմܴܴܴܕմh#Th7zht5h7zhrs5hThrsCJ aJ h7zhjhThjCJ aJ h7zhHvJH* h7zhHvJ h7zhrs h7zhZ h7zhph7zhSBH* h7zh h7zhSB:(),25opqrzYZ[eqrst/NŹ~~ses\s~h7zh3G0Jjh7zh3GUjh7zh3GUh%9 h7zh3GhTh$n5>*CJ aJ h3G5>*CJaJhjhj5>*CJaJhHvJ5CJaJhthj5CJaJh%95CJaJ hoIhHvJ h7zhp h7zhjhv htCJ aJ h7zhrs h7zhZh#T  ! !!! !9!E!j!k!o!!!!!!!!" """"#"+"2":"C"N"O"^"_"""""""@#A#X#]#o#p#s#}###︱踱裸踜 h7zh$n h7zh1 L h7zh<4 h7zhj h7zhagh#T h7zh 2h7zhWH* h7zhzh7zhfH* h7zhW h7zhf h7zhth7zhj5>*=O""$ $/$$$$%%%9&&''((()))k***v,gd .gddOgd+ggdTdgdTgd$ngd, & Fgdf######$$ $-$$$$$$$$$$$%%%%%%&&&&#&8&\&c&d&e&k&ɾyrkdkd]drrk h7zhz h7zh:6 h7zh3G h7zhagh7zh:65h7zh$n5CJaJ h7zhfh7z5CJaJh3Ghz5CJaJh3Gh3G5CJaJh$n5CJaJhThagCJ aJ h7zh 2h7zh 25hv h$n5CJ aJ h7zhld) h7zht h7zhj h7zh$n$k&l&p&&&&&&&&&&&&&&&&&&&&&& '''''>'B'S'T'Z'b'g'k'l's'v'w'x''''''''䭥 hT5h7zh 5h7zhg5h7zh7z5 h`h1 Lh`h`H*h` h7zhdO h7zhzh7zh H*h7zhgH* h7zh:6 h7zh1 L h7zhg h7zh3G h7zhag h7zh h7zh$n0''''(-(P(S(b(x(((((((((((((())#)')I)K)Z)))))))****** *H*I*i**********+9+C+F+L+Q+Z+c+d+,û㫤դʤܤ h7zh .h7zh .5h7zh 5h7zhdO5 h7zh+gh` h7zh1 L h7zh$n h7zhz h7zhdOh7zhgH* h7zhg h7zh @, ,H,M,Y,u,|,,,,,,!-"-J-K------.5.9.F.G.b.h.r................//1/2/5/G/U/`/c/d/////繲૤૙ h7zhIh#T h7zhf h7zhaS h7zhB$ h7zhW h7zhgh7zh .5h`h .5CJaJh`hg5CJaJ h7zh1 Lh` h7zh$n h7zh . h7zh 9v,#---r..///0B122r222355555G67J7X8x8gd`dgd`dgdTgd,gd .//////0$0b0d000000000000001116181>1@1B1z1122222#2.2B2J2L2P2V2a2p2s222222ůԘɾԉɘh]r h7zh_;h7zh .5 h7zh3Zwh7zh H*h7zh .H* h`h`h`h+gH* h7zh+gh` h7zh .h#T h7zhW h7zhB$ h7zh h7zhW5h7zh 5 h7zhaS42225 5i5j5555555555555566666E6F6y6|6666666666777H7I7J7M7ɾ鷩鷩rɾhTh 45>*CJ aJ h"CJaJh]r h7zh" h7zhxC h7zh(h7zhpH* h7zhp h7zh 4 h7zh8h 4hpCJaJh 45CJaJh 4hp5CJaJhv h CJ aJ h` h7zh`h7zh`5h ,M7N7|7}777777758:8N8U8V8Y8u8y8888888899999999 ::]:|:::::::::::::::;;;0;1;2;3;ݰݷݡhThT5CJ aJ h7zh:h7zhxC H* h7zh #h]rh`h7zhp5h7zhpH* h7zh( h7zhTz h7zh" h7zh3Zw h7zhxC h7zhp h7zh 49x88K99::2;3;@;;&<<=<> ? ? ?S?T?????\t]tt .7$8$H$].gd'D 7$8$H$gd3Zwgd3Zwgd,3;@;B;C;;;;;;<<<%<&<<<<'=====콮rcT=,hv hmV0J5CJaJfHq hv hmVCJaJmH sH hv h2-CJaJmH sH hv h[hCJaJmH sH hv h. CJaJmH sH hv hCJaJmH sH hv hY<CJaJmH sH hv h3ZwCJaJmH sH hv h3ZwCJaJhv h5d5CJ\aJhv h5dCJaJhv hFICJaJhv hY<CJaJh7zhQk5====>>>:>;><>S>X>Y>\>]>>>>>>>> ? ? ? ?*?}}}}}rcWHchv hoICJaJmH sH hmVCJaJmH sH hv hmVCJaJmH sH hv h}yFCJaJ,hv h}yF0J5CJaJfHq hv h}yFCJaJmH sH hv hCJaJmH sH hv h2-CJaJmH sH hv hmVCJaJhv h}yF0J5CJaJ,hv hmV0J5CJaJfHq hv hmV0J5CJaJ*?R?T?Y???????t]tbttttttuuu/u4uHuIuuuuuuuuuuuuuvvֺzrfhzBRhE5CJaJhKhE5hKhE5B*phhE5CJaJhohE5CJaJh;hE5 hE5hKhE5B* phhEhohE5B*ph3fUhgEh`5 h`5h`h$$h`5hv hmVCJaJmH sH hv h7zCJaJmH sH &Moderately abnormal trace: Lower margin <5V and upper margin >10v. Trace looks much wider Fig D: Severely abnormal: Lower margin <5v and upper margin <10v. Trace looks very narrow with spikes Reperfusion Delayed Apoptotic cell death Immediate Necrotic cell death Mitochondrial dysfunction Capsases activation Increased intracellular calcium Reactive Oxygen species(ROS) Nitric Oxide (NO) Excitotoxicity Therapeutic window Hypothermia Other Intervention needs to be with in 6 hrs of life Hypoxic ischaemic brain injury Secondary phase (Hours to days) Between 6-72 hrs after insult Cerebral metabolism transiently recovers Primary energy failure (Minutes) Insult ttttttttuu/uHuIuiuuuuuuuuuuuuv$v%vEvgdEv$v%v5vDvEvcvdvvvvvvvvvvvhv hmVCJaJmH sH h/ hohE5B* CJ$aJ$phhohE5CJaJ h<hE5B*CJaJph h<hE5B*CJaJphh<hE5CJaJhEh<hE5Evcvdvvvvvvvvv 7$8$H$gd3Zw$a$gdEgdE 21+:pE&. A!n"#U$U% K 01+:pT. A!n"#U$U% P0 5 01+:pT. A!n"#U$U% n@E+QPNG  IHDRů6sRGB pHYse#S?$PLTEw .7aJUؘ/BIDATxrF>/`+đxI9b7>Q0 @)ɞD|l 0s' b믿Ǧ['ϵv)mVvXf:Cg _;*}z{s}7Zbd{9Eyu, XJ`@W@%_f@S)óuQ=gbg}/=.Yt]үաu}' Cd{.ZCA[gv Cn:^r ˲%7ܔq*Ȗ|-i(en|__h tn=zoNDx8R-W='F4΍h>>6;ȾTuf]vÁnh P]ڵx|InѠw3Ѡ{о1?^i/ Gi7WΪx@q:wN <vu?~n4Lh1oW= }|?R-["Z)G鮴;G3h2 WBjhhWmM<]I]}*4(֑zhA wwMЊrQ@nZhjwn=Ơ]$y'urxqh&iWs/ -x]ԁ ځFK_uDjhQ- u>Z4zhщ*f]Vԡs6nHfЀB LdE7,U=st , z Bc}&-\o\`˽@/XR0M2/XZ7[`QW1^G;Hn-]pO殣y%Ѡ]Cv! }Khڥӫ/ę4Аha$R$# 6Gk,ۣTzA p7h@ hWN#ҏćJ"79Z42Ф5Nn?B& 4BCZPCc  Z4@ơmh+$e ?MFh@SРBkRu!M 44mihBSZ{@kz4,`6N#Ѓ˨ $MjV{и Ch< H@C s1hl%*ZƆևqh&1hhq:4h.CDh2aM h M4Dnx4AqhHBC 2=45 ԅxt؁ / ?4- 24M-BMh449hi5h }Eh\}I:C_)q"4WH:CO)C_^"tUC~y@3A hz@SM1C t4^^94Qht64]pUu4·5i64 34/׆A㛃s9MC*Д04ǿ 1 ]AnLAuqa9M4 @ӛДu[ x4+f?R~(A܁ƋBہ484K:AIh!hwM8 ^ 5SM/M+@c?BcC[ŕ.4 Ӡzt h;@s Sqh< L)Ɨf54v9ֻ!h -84M}h\m4qtѴ>4 hB,^Rд4͇y{ECSZA(ǡy%h\OAcM ]nq[hnM=hTh*SR ch)F.=½`y~vQ(+(ˢo,)ܶirlRr6hډJ3rDi;Ew( @a. =IDp(hHlo)_H^035ҜS_z(hl"ES?ɿ vAF4D45s"MF#'#":M!4vy4М4ASM@K>.Sд hDM-4%~7V.4-uu3 Au.@cu: i]м)qиkhԑB3Bv޺Rn]rۼ|ͼByweV˕HeKo!mҝ[ }F$IRficv{p!-X )'89׫J[%T]As=\zlhTh &ADstЀGOdG0F>2DuDs:LoemDF4ED4G4hی"Z`PC68 c<AS ?#8)h@h}-U]h<WR#h d܅A )CIhZ?B[Mؼс^=4 #Acw{܇Vt)khq>t?ͣ|64v>C vMҴWg4RiAihg@"v@sCh{54wQOMr4@ޓ#76s <ihNB<mu譀/z<Cs͆5 M}yAASF1O^,ܿ-YmUqK"]*j[JKŁ2Zz+Wm֫ʞd]zeT;U{^ekeU]:|UUgbЃlpڭ.v;>A׍hNF4"تqDs/ͿQԶG۪em)"Dmme媡ˊݍ4м*t|4χМ>AcOC3o3H8Ih uy@(~kUp\%b<S!4}ԍB)h\=:; #C 1tRГp,h^ !0iy<(Q0g+ cK͇y ˲S>M6&sq^mӽ9LuqO.<*LL!ן>}||'vُzB:+'yj-K3ܳ':3~x|x~q{&ZCo-bVh7Џ2pZ.*п|yH)~#fakm PGtNMr;7!SmbAoIoٺۻ5q;Go?=*o.q{7]h从n ],X>(W*т%;1 ?gk$7EgWۧ'IENDB`n-S<$gıNPNG  IHDRz査sRGB pHYsr4A4A4A4A4A)@(Dy*\UA/oS+m:'t}kշ)ٿuVza=fn&:j>ַyUoSԪWI mu}{:tz}.{"(e s'+2r+v^V TV B0xF.=D`fni+UiA'zClRrw\ؚLw.%{K݃{7_z>ST8:})dWAoߦdsߊ |`JT?ΨtdhО۔@g=U؛c-cG:]3_ciL_fM@?/Pl޻7ǚ>[A?)'@7o{Pf o{haWNo3S~Ku'Dy[yoqn2õԷ c'g6@ߵ=S_EA:6*oqfio~Lnvҟ>W\n6>݄쮾OЏ&L.cHg]Xz}_ ZX3;YAYFp_6KK>Ͻ[SE~w[gп?93/ԅCvq38}]OO#}s*_@=hW߲_uHc-[:=[FmJog9;͡K$g9;M9՛.Zߓ@㪠ӿqv]E{]{]2ٮ"M}(h4A4A4A4A4A4A4A4A4A4A@  h&@  &h&h&h&h&h&hOAɗ5>*NuAyoU6VՎ0Aﹾ9,Q|LtE3A_}hq,rh,@wdv_4AhdR|Fh1=a1yQh"h]t9rt@c4S4փF1;Z=Q4~1Yb4^nV׈A0hLFh@E1ѫ,hחS6+ `Gyh(hFhF4 "߮!AhvWVaHF>hn h@#5 fƞ1gl{F8qИ f0f k@(h8h57h̀ƾ2@IXӠ㨮w2XU]; 4"X1@c P3 b7 1۷"1 4Ҡe4h$@И= C僆.7O^IH6u% h@h40!h1 Ac"HFڵ,h$@h F4+h\4@WqB(/184jҠ=@Q4b hT{Fk@]AĠUAm׀F4@+C,hLvWqJF1*uᒠ!APИ:j|^ 41Zu9cVzhTZm h,J :A+] 4Ac4^2BA 41 ٠MG}$Q%({Wa*CAށrcr!0P)ԖߜQ/ADv[bW.Gkd3++fS#miqUn[W:^;ӈ 6к"zuxJt6g[v7<d?^^ڛi##4ʌ2Bc Z]0Bc#4И//A 84zgUŠt#Qv=a[+,+a% gU0 \4A+*nD(/kmr{ psYlxNoT뷁R5lshQpƢ)G##4g mE WPX| 6Zo3FMUo-i]]9mo$܄6X&NH4Jǀ}9plI\Qr@b&kGhFhW#xazRvDЛAc46FИ !9=cYz)ς^`j1O'}se@c4ИP$ U+}}F^:QD NL//M_)]U^t#HpNe9E7NM}r^}@ynuZ_^ :=6jiF5n='\1IuXտt%K"U5B]ޣʳT.{H:"ӗA;Eo mSe=6Mc%SZۇ}»Bzno})F|02Uɲ3hIAk6};:ܤwN׾ވz&8àm` Z?׺{fDS][[9fiGA/yJ&8a'.xOUf7Z oiT?;,m{Ҷ}l]s-{v -!ɿCQRblTjr[-/ zaݪOkHMmb!Wצޗb4*_d<P߆@vjdW?Gq7ZԮpY[AB>xR[Hn8\tXNrvԎmɗ{' B~E#Eح^s_al↉Fp'bVvtfeywUdywĞ9 oχ=uo/Wt<_GЄJ2mLnSs,9B_k&T&h#h&h&h&h&h&T&h#h&h4J!2GZGhB%苃V2_t ל4A44A4A4A4A4A*A_t|Ee^a9S;7%ӅA34A314A3v37ݽ]<<%LN7|ߧO' ]'q+o⟈rѝ^=?4?L.\.ZПGɏ ]6*]ӿ~]s?qne7/9ո٠Ì$ar]3!﫻f0'V b]& LCs4蛛$o<:v'ᇓϮz% _f?/gzПݼK c|t??{ [2y')ǛTN`Nv7kdh}=?(t9?o0:qP(AsƧǷ/G661ft&9tw1xyc~4sa˟r|Irh%r +t<5aiϊsiQH73% h [왠2@~vcb9$ A3 Aoaah Ct{Lmaah C!haf!h!h64aaaa0;af!haff1 Aoaah C9 hH Va-=ksah A+;Yv`-m^7l: *? 廻LlmYVm4A3hžYv`8-n7lW 7 C 0- H/W 4A ) aK4a#ХN{PAؐMi}xh&KN'>h/Ay : hJ#~IOhJ#W4A_ tєFi4At`g 4A->ZDMДFЇԦ{k8mJ$@5צxJ H;0@>荢Ohі^6tYB>{#̪F0mj,.8ߘ'0fDz.lb3? : UFV2 7Ö\ҢTn@ I=r)oUY~_r+ a&)/2[J ~Gq3JJTʴJ7MPTؙ5Ӆ3y2;ZeP9AƱh_MP݉!튙l9#sSycw-ަC{ [K <_\aX3QQ3-VOWӠ`菹ݍ˅i(4D1dFT8Qmux뽆vg?;%\J O#F-CZzxY!Qvb,#-%Glq|Buw\M[r#T}â|6#%Ty4,`_?t k W;*4.0CadxWY0Iaah C!haf!h!h64aaaa0;af!haff1 A3 40 A3 A7 C 00 hKFv\-=ksah A+;Yv`-dVY-|8Llm7saUhM Zoah+C FBo 40 A3 44a}00 C 00Fcf0 A3 40 A3 A7 C 00 C Cl4!h 40 A3 4\:6 00 C Cl4!h 40 A3 d`" l/IENDB`nRQNF^! hPNG  IHDRzrsRGB pHYsr'PLTEw .7aJUOhmIDATxM863y q gB60!j@#+`#F;W"%RlESءOIp*>q|K/@ @ ֡|<&<iq_ `^NM}K\Zzĸw4ǁ~Syiq_fx<Տeǵ]V;PJt׻ĝ[B\LEf/̗F[[P&z fA7kbg>5A}q-_~J ۸ =;.ѬZU}/ݯ<5/'m ǿ~,_.G u݊kR:?nԏ.kgu%u`}$tz#14_1 Kǝ==~:ԁ"qG3~9Vqn7wqqK*vܤDϏ;4+@ B/^MuX:aw̸]4+nr;^ i/"VΏ;f gu.i^䠒@ @ @ @ @ @ @ =Io  x4ZŽ .}OJCTe|h4zB~>9CwNҁz**W}4-MKC]U5*΂~h@#}Th4Bq@!4@6z+XM!tn)QPC28Clh A! 4@SzOh\#h,6NN;K/bN!к) M@m{I .X!4-77q445؂Ѕ>h )Cc] M%8Z%& 4A4:h1%@c4RE 4M4Ъjlu:3T ԂV3Yh U/uA8Zth=CS54v̨ FInA(h(Bh4>1TdAzFB&<Z BEB́4d<4Bmކ->U/'FrSW].XӤ;%Nɨ\]uؓP+UOl켕θY _d8UE/],U&~_'XgvT}TD NDw` [J4]oJhvʖh-;_adPhl2ò,. ࡱ:mh2U: !J@Ba m6n A64 ڶtgYhB. ]h[܇?N vCcd}Wb+h(vteA 14֟~к CCx[P{)cdk (lJ{v) @C ]hX=4AC44@SK%:7nf@m K@C]Z#}@hhx.OG mn:`-i=zʷ,h4Ц `p<#cBGC4, 7.8wM =e B(B7]9C  mmC/0̅^*r z钺.rY &Bgӌn@_p@ӡaqЫ23 Y:yI6ۄv@Z:r7M?4yi4yQ4e#*4ggBS{q8y%'qǦ]q}hwc}jYM"dFf]S=Mv.MeC)4ЈohG'̄AU 96D>@^ãq.=8=LOD&d9 &CUXm@OUhH[LM+@Wd32q沨:%ˠi:BsBbД6ya.4M4KhF1W<^~ۈ.14֧S`Z bf@SKiC&n9hZ -hCgCLmS]xYSUznG SUjlrBt\v4+3\>D_`s/vkIu+s ߮MvIvzjQsհ?腺 :%n)%޵K\_(ݮ؞_̢uqٹw%^զF鍱neaDи4cTc4is4vks&Bs s4uf\LA<>ӡ) @cfͳ9 j} 0+%JC q4C4J4f64Fм4fh ͳڡ'CsMSq1hh<4h>j4Yh<mvq 4.Mci<4-4CИ 4栩4q64vC흯t}k~hĉA;̈́ 4'A 2b#.4zh64q4A!ht܅.szf|u-tDŽa^h ;<9 M546x>Os!4@s4%䡝S"Cs{_ݧ!147ИF8S c41&W9MkhBh.4:z,fͅvKsAhnnlqmh mo5#rh\@dWy:4q4cBsChW{19h@c-{vFy1,9HDZд4wCs?4w[> 4w9HA7OJ~hA㍠y4?ǧM`G:м>4gA<.45;042hC+ AiS77@.4<TChrg}n1mrA/hܦ/|mih>O%9oIh'CД63kjBf t/kactbwj n GL+&U@ F @ ^-j-U@ @ @ @ @ eP hhhhhвg({Ru@ @ @ @ @th3=C:z<4&F6>YZZZFĞ$l4O_j|j)/Y?~IX'h7?{g˼/_>_/V{׏=OO˯}틆&~~m~IhW1/lPOO~~?|{p Ez-fǽ~ U[utW>?5񊸃VŸT_SB?<=hϟж$UHTmkd|UIϟ>/f?k?~6uG6='[u<3io} 9V9g_?`U!ki -}1w=;;Wݻ/o?=<_jDt#Bp;,x~âEt;,?/4SvXd9|)5ȟz>gFZZZZ,yOHڇ#---------------- z<ޢRI>,nOAA6 }B&@sV̝;Ɋz`ӷ{z%M },uЧ к~ihݏQ@ @ @ @ @ @  M @ZZdž!h#*4uVBW[@3NLo LXC5P6 MC.FE=Jt"^\nn=bé@J,Sj(^O;um X~,48Qiъ3|vv Liny1E@D C(Ԩ!tF$mTq'_E*c8])48h_ZuE MMehfn"&iBKtڦ\}A0Z kȷݍeϠԛ!pSyuV ͣOqx c鷦*v [k{jG8ʠ =.Z-B!4y 4hhP|mh:u^tnhlRaIu R mw+@q[bEai+TGB7}haaE3SJTHq1z4 ݭf2e\̵,5-59Rz:݌ET*G_*Rm 6eɀCl;?v; 5)%>+ ϗlZX[L T]~n~6 {sƠD{D7RBo[~ Lvz}OBFXХth,vf&8E4@ۖ\@Z^j{<%˫:=TW7F+΂ўljj(eu1 hۏSM륺ˇ=銡i4 d>eCF;lv;5&mC7[EO;H#hl۹k+1 M[RK4E@͑>a64Bmhi']1t:mt)_0QcjC2 ]gA[˵ݱЭR94L,$ 66L`44PTMJ7 4C.4FZ(tk2:Z=zI4m{40FwP_H9[}LzFz4t"i?hT9La"4И56M5V׋BSvryL}EDBZ uz5qtbDzi0ۣ MA9 ϙҳ++G)eWhtbA㍠@}I tшegIzl 塱$74X34 7 Mg}`)2wΟzOh]9r'4`>zqwvͩTI%0cS8~h{0B8hB0"7"4z\nh4[A㦡{wt-8ୠW-=|~ϭnCo&@л#ʓB9hFyhdB' 堏~OڥJgRJݪg(ud㡙J:k.4A} 왓84]`|x/LR ypApvun0OqO;v_&.&=3 d7! wRr7t>E Kl4~}|EPB&o]X694jY]kuZgMx6\ˤ3ӎ.aO3Zwe1v 5Ӣ$C&ҧ#bMg7aag4OSyѢM}ԧej<4'"tX!8?VrAͳXy Sv絟!}=}h^ug} ?bS}gɮDv W{/0-uY'[}aI" ՗[|JKtWo(obIJanaP?NDqJW({ƒ$.;4Y}&`?q)קW_<=J](0~xU+_z-4:*q#UÑѩS*_G%FY%_|ԑ|~0y8<<<<kX{Rx DEEyyMQz-((((((c;;>=7GF""*AL+v%㉏?yyTG?ȣƴuرsß=*a6*ߒyd˖0&G^GGc}dSWZs+0B[nEkKEylyy sRm#ӇyY-}v<2Gqo5<$._ʥf>2/u|5v<_8Y!}d#'–HÅ\Ĕ˃Kl*Yi$eydf#yKӾy' Gs1L:tg;KsSǫÓk.Ŀ7Z|*=#9"/^{i&f\;|]:.䑙3)uk],4xcb͑ZהʅOoKwv|k .pd xdz^fm%oo :{Ey$y(:׹x$곢<ܬScx$6WȟI庸{sQ:3i–<|ݿһcvNa)<{cf;gN{֥|:@6O}Tn]my LVGYluJl3KUnCm*ur-|p24n\J&^3q::nxg[ j9ZQOؾh!nB.ƅpRDUp 6OOW7)Qc79q+~ItnUn̖ N ,Lhy-i-^[ߵ fl9WA2uV4lV­]lo7;"Uh^p+sN(전M7(?n}PH19qxBІ6.IC-97 nb`o˜=8܉[xfA8|*T"kҧ~f`._ \=Wm>63th A͹N 9n !bEО&ʞsӗw)~+:1ۇ?n|`-oP[l2Cܠ8Aw =$u/W |xAT9.BMU= @Գ~ 2zL;Mb!0n==(M|mE߾wnqp7bM670/h,@aCME/8qUPXWo\fSB-o{ MtՇpBJ|B3 6nXOpA`g>vW+fB*CX!FnGŻ$[`q0TBd5s>A{jBFFQ8q0J(7G@etcҳ 6n5 NGcF|.uf9s{'{Fn8|)?i`n`&(։jz oOqMٲGҜK}nvqIIL;iY’/t Uyi&&\wrç/ܯC%fƧ |-nbsV5A7 τqz9{*[F:|EIp Y L92q oG 7k~Sgpٿ?:)Fn6HIq6tNhRLaj 7{A7uJS]iةX(3j߲< ps @qÒR* Vn]颸qYP+xĹ긑~34| sarˇp˿\Kp T7a&vSpw_#;!p#K8V?QpAB } 8z`+W[oІ~=f/H==` R71}q{~m8D-ݴm3XpCdnyf ~_~e5u cwpxuT> ƍ9qVq~_K#q]nzBCPa- EC=7a9F7~0[Oqs OO-ܾ{5w ̠ݯ <3 n3`@ ! oJ;E1nP_ J n7]s'xΆWޝ߶oD/EXw @+m4[37.+N0PJ 6nv i+ dm?=qyn)P#tnGd;W"bŚŽ(< f @{xAJ}MٷEq۹&Tqܫ<Jz_|Ds&}ExdpC|:7#FKl yE4t;BO a(*ōVze'ay$o8nIބ,[Y"[wF9`"qM($Yryݗn7'-Z+qqEyTlx^UXֱ^Ge)e?t(ׂ!y+=g ɛ/Ig̼=!꺢8B)]'O֋Gq@p[ӼWmO|&*5}ZnV JRy]ጉ?lֶρңut群~NWuygOK$͟ G;eߙshҼy39W'.vgnҼjolx̉_= rIj?c>'$/l~Zv֣~}[)i3匉C& p K>dDdrk\wuE|vzg殄3 j6IgWN1>mvFkF"n[Oĭ%o,[*ĉU l$(vI6[-qvIlDyz2qEb$Kb$[ԓ[-%]m6 kW`*Zĭ]q藈[2PqRsZ-Ɋg+46h>[dg c>[Xp5vmE=i[ĭ(ocKF aE;W-~kCqe-o<Ŭq*k7r= lF[^dΜ?nTtnbq_Wn;V/%j*љޝis.K_n=br4nip+!Epfo\|(ĭjOp nF4Eܬ}Su7gVumq]3]7U7f&au7=1 M)s L[7+p7_PEq-6.ƍ3fJ[} h B93ka▿SEMw.<ۭvB+[`Ҹ]=K㖧੬e#pCq㻱97 7;aQ9;'no7^lxLl[n"n{ܨ O&X7R}p9wnqj{0nXVJn| qCg7m܀abS0n`nvQn[p-&Ѵ>Zi^7^,OKދj {vøo)5߰,ql0`: 03N[>9~ҳSVNM7[䈋6(d# c=}\ȁ7 @Q\7.Qvv AƀCv )74[1 ўzlUǍ{~0q=mE#(n&$61EISHayZq Oa |!ikE[ MN©X!Sp@Llq#gih+yp,3BsfNt!nԄ[i%P!Tsmrcx u&n`VYÍWȧ:7jTQ.q/̙\'pqv:n2QOؾh!nB.ƅpRDUp 6OOW7)Qc79q+~ItnUn9m~jn² nMMzhΉ3%p)&:x;ZDyunĭw-1àgp3[7Ub.l] %936*ºp+l/d|jnt*.ʜ.-]&ߦMԃ~g? l^Y6S?Df4_: g,S* ڣ71J9~q֞3˾S0l^?@6 m F;x n [Jml`A 7;(a @B@d.pEnp.ḁ͹KGKMo!>0fwsJ!=-/5儸ǽ߽}o7˗B8WU۷ L(]3ڀ@BPsSmBl7g_<<<|r_N O1z<o[7(?(N]`e :m 7vC1_U(` PSa}@a,wC; ~+ӷ:|08냘_7)$kO?m>/d/p_[8pѷ[~ͽXShm; ~h&̆K"9 6PPSQ ND{w\)DՇ*$cyP 7>Cj]F(ntF7"LF!S %8@`Պ#+VwvFQ.{14*pg' c1E"DE^|QN1jPY0XlmqF=} 3QnK+pw)p^ɞ73|-)pO%- JuƧa&|)~DF>qlFl4璦{r_?~f|DR4Nb): ]BDUfI ~3G ـ|()|+ngUM ¹3!o^^㖤.D}fgBb=ܠxOjjJg,Rt|RM4Suz}f#ڳӧ8nZ^k j]>Tn<`v*V" ڷ,OB>ܜ-liܰdm/ [W(nny> 9q:n_ \!/&+MgfC `N*vu#scwP}#}`ζ؊6[1_ Rh,X:"TMqLfa^|E(N(QD ~7tfہm l0zـ0l޿Cߗy|M].qX;^ս7qENܨ*߻%W8H|EbkXx `- PMX}̾SoSKy_3vk86 @/ëz2d 'C'n3Nq<"W[g| (s6aU7bwrp- u] PhC+;. Lꍋ=  Tm҅wvtÀBisJYziۏtOܻG@[x 'Hƺ|ΕAfq/ !О^bgvS=utQvn U6j⇪D=I_.<~>1߷N h;B^7 z~ /SBF-& nvFsq#i^iI@Xx8>2C{[7!KVE-V9zN7!n\ =I\Anx}m[ I$2q ֊p8zo-qU-|+uWrYylv)o'ʵ`HyϙB拽z3oOhq*nJ}mF>xɓ68Qu ;4q8;JԐ114/5wu \Ѝ:CW̝˩" pq7|%p]q~㜔{~dG+o\S}w"KT[?\sp{`>˘.=? Y|>Ԭ/98q~QzԳW>dti`jZ*}0NMDd$(#PD  3 @@"?DyK www.npeu.ox.ac.uk/tobyyK <http://www.npeu.ox.ac.uk/tobyL@L Normal$CJOJQJ^J_HaJmH sH tH DA@D Default Paragraph FontViV  Table Normal :V 44 la (k(No List 6U@6 ag Hyperlink >*B*phHH nk Balloon TextCJOJQJ^JaJZOZ  Normal (Web)8 KCJOJQJ^JaJmH sH O" Qk Heading 25b$d%d&d'd-D`@&M NOPQ5CJ\aJmH sH &O1& Qkti2CJaJ:OA: Qkfeatured_linkouts&OQ& QklinkbarB'aB siComment ReferenceCJaJ<r< si Comment TextCJaJ@jqr@ siComment Subject5\VOV 5dDefault 7$8$H$!B*CJ_HaJmH phsH tH *W@* mVStrong5\P]j1Ag%GO7 QONMLKJEDCBA@P]j1Ag%GOR  M7~4~~fglS_LMz  @ A  v w z { | } )J%qrZ[stOO /9k v"####r$$%%%\&&''r'''(*****G+,J,X-x--K..//2030@00&112<3 4 4 4S4T44444G5H5555555555563646T6q6666666666667707N7O7x7y777777000000000000000000000000000000000000000000000000000000000000000000000000 0 0 0 0 0 00000000000000000000000000000000000000000000000000000000000000000000%0' 00'X00'00%00"000000|00000000000000 00  00 У000У00У00У00У0+ A(#k&',/2M73;=*?vv #$%'(*+,./01345789=O"v,x8tEvv!&)-26<>v"7_X_b$@E+Q~b$-S<$gıN b$QNF^! hZR$iR:5gE"$O,xAq,Je0@d#(    $) >3  "0?` ? c $X99?$)t @ S @3m"` n A C A"`  n B C B"`!$ n C C C"`d!!! n D C  D"`<$g&  z E c $ E"`g Y'1")  ZB F S DtuxZB G S DtuZB H S DE%%'fB I s *D38cxn J C  J"` 8  n K C  K"`Jh8  n L C  L"`J$x  n M C M"`!b>$ z N c $N"`=!$ z O c $O"`!$$ ZB P S DtXtxn Q C Q"`W ZB R S DtXtZB S S D "V  # "? V  # "? V  # "?  V   #  "?  b   S A? #" `?t  0A ?? #" `?t  0A ?? #" `? t  0A ?? #" `? \B   S D"?\B  S D"?\B  S D"?\B  S D"?B S  ?w x } ~  7>"t X]!)tn] )t!!@t@t@t @t$tHtXv!tF t b%QtxQt  DOOT\[[y,zT$hh!"(N-N-0111?3[447    jj'"(U-U-0111I3a447 8 *urn:schemas-microsoft-com:office:smarttagstime8 *urn:schemas-microsoft-com:office:smarttagsCityB *urn:schemas-microsoft-com:office:smarttagscountry-region? *urn:schemas-microsoft-com:office:smarttags stockticker9 *urn:schemas-microsoft-com:office:smarttagsplace m175578HourMinute   !V[swt3!8!'#1#F$T$5%>%&&( (((A)L)d*i*C0L02 2333333 44T4666777e(+ L!Z!#4$U%_%%T477333333333333llPPSSLLMMN&O&T&T&U&Y&****++,,..S4T4X4a4X5a56 6626777777S4T477(A2`,>2-o~v ^`OJQJo(n ^`OJQJo(n pp^p`OJQJo(n @ @ ^@ `OJQJo(n ^`OJQJo(n ^`OJQJo(n ^`OJQJo(n ^`OJQJo(n PP^P`OJQJo(n^`o() ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h ^`5hH.h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.(A,-o~sR|*[䘈@dtBU         y        #9MSO HZxxV] ;>SxxVn! ~O~xx," g\}'sxx.>n! xxsOvxx !%$F%& 3xxY])0X9xxeN60Oxx 39(QxxB3Y])xx1W.9," 0X9.>xxnF'xx%$FmRL P !9(QeN60xxMSMS'xx>SVxx HZuK\ !g\mRL <iN0]%&xxx>dY])xx\ o%&xxOv ;xx~O~V]xx[h. g-gE:z]@ xC ~ 3G:p8aS]v I!B$E&Y&PC)ld)/ 23 425[6h8Y9_;%<Y<R >'D}yFoIVJHvJ1 L MgbM_OdOYQ#TmVPYLe[{I\`_a4dag+g;isiQknk{yl$nnYo1kpr]rms3Zw9}};~Z f .FIWp Si 9Fp Hr@w<4&JTz*5dd[ #{(IT D,";yzLq%go'JE[VetZfjSBrsw:6$$2-7zpRF0D~P/A{.+3%99HTo'gS47@x-1X&'47P@PPP$@P0Pd@P@UnknownGz Times New Roman5Symbol3& z Arial5& zaTahoma;Wingdings"1h<<+f,^,^!nUn+24d:4:4 2QHX ?ms2AManagement of Infants with Moderate or Severe Perinatal Asphyxia Julia DaviesIT Dept   Oh+'0(8 HT t   DManagement of Infants with Moderate or Severe Perinatal Asphyxia Julia DaviesNormalIT Dept2Microsoft Office Word@F#@r@@,՜.+,D՜.+,@ hp  "Cardiff & Vale NHS Trust^:4' BManagement of Infants with Moderate or Severe Perinatal Asphyxia Title 8@ _PID_HLINKSAtBDhttp://www.npeu.ox.ac.uk/toby8  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry Fp)FData 1Table'NWordDocumentiSummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q